Healthcare Provider Details

I. General information

NPI: 1366444739
Provider Name (Legal Business Name): CORNELL ORTHOTICS AND PROSTHETICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CUMMINGS CTR SUITE 207H
BEVERLY MA
01915-6115
US

IV. Provider business mailing address

100 CUMMINGS CTR SUITE 207H
BEVERLY MA
01915-6115
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-2866
  • Fax: 978-922-0277
Mailing address:
  • Phone: 978-922-2866
  • Fax: 978-922-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. KEITH DONALD CORNELL
Title or Position: PRESIDENT
Credential: C.P.
Phone: 978-922-2866